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San 9oaquin County 1868 East Hazelton Avenue <br /> Environmental Health Department Stockton, CA 95205 <br /> P Tel: (209) 468-3420 <br /> Fax: (209) 464-0136 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br /> [Tattooing Body Piercing Mechanical Stud and Clasp Ear Piercing <br /> Branding ® Permanent Cosmetics <br /> II. REQUIRED REGISTRATIONr PERMIT, OR NOTIFICATION FEES: Check all that apply. <br /> 1[Annual Body Art Practitioner Registration 30Mechanical Stud and Clasp Ear Piercing Notification <br /> 20Annual Body Art Facility Permit <br /> III. APPLICANT INFORMATIO : _ �^ n <br /> NAME: GI 4 byilwt ' Y, 1 �a q Phone: ( 209 IpS2 ' OVS � <br /> HOME ADDRESS : I u7 5i Hol11M tto% to . Email: ) abr • llPiiw, 23� o{w.a 1 • Gown <br /> City: M o d-eS �-o State: zip: F .15 3 51 county S;LA WS I aAeNg T— <br /> /�' BODY ART PRACTITIONER ONLY <br /> I - <br /> Date of Birth : 10 - q7 Gender: M or M jcIrcle one) <br /> Identification Type: Drivers License Other Identification No. : <br /> Facility where Body Art. Services)U l beLProvided <br /> FacilityName: C l I-2 Owner: Ih <br /> Address : e 1 m irdlcia- <br /> Evide ix-months of Related Experience <br /> Facilit Name: Owner: <br /> Address : <br /> Service You Provided: <br /> Supervisor Name and Contact Information : <br /> Bloodborne Pathogen Training: Submit Certificate �•�� ,�/I <br /> Date Completed : = S Z2 Training 6, <br /> Provided b : �f�� C- G ( V� I n r " ` <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> 1®Certificatlon of Completed Vaccination 3®ContraIndicated for Medical Reasons <br /> 2® Laboratory Evidence of Immunity 4 avaccInation Declination <br /> IV. FACILITY LOCATION (S tttaachh additional <br /> sheets <br /> -aass necessary) <br /> In BUSINESS NAME• ( ) (Lx. y—USL IM C/�TTCI�� gl l .(/� (/a. ' <br /> Location address: MtkW4 , <br /> /n 2 / Suite: <br /> City: j(VVA r�l { ( State: C PC Zip: �r 17 �n� /7 nG County / '� \A /,�/1 U I V1 <br /> Owner/ Contact: � t ) � V nJVI Ol lVldlkl� 1 Phone/ Fax: / 6" I - Ul� -�" I / - <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City ' State: Zip : County <br /> Owner/ Contact: Phone/ Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing . <br /> I hereby certify that a bgst of my knowledge and belief the statements made herein are true and correct./ <br /> Signature: Date : 7 / l 3 / 2 't- <br /> Print Name: » ic ri ` ✓l0. Title: <br /> FOR OFFICE USUE ONLY <br /> Program (PE) IIID _. Fees: _A I SIO _ . Authorized by (RENS) : I � 3 I Date Entered : I ,I 3I LL <br /> f2 <br />